Difficult Airway Management | Jindal Chest Clinic

A difficult airway is a clinical situation in which a medical professional with training in airway management finds it difficult to use the recommended techniques. This presentation gives an overview on the topic "Difficult airway Management" including: difficult mask ventilation, preoxygenation, thyromental distance, laryngoscopy, cricothirotomy, etc. For more information, please contact us: 9779030507.

1. DIFFICULT AIRWAY MANAGEMENT
Tools and Tactics for Success
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2. First Case of the Day
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3. ASA Definition
TheDifficultAirway-
isdefinedastheclinicalsituationinwhichaconventionallytrainedAnesthesiologist
experiencesdifficultywithfacemaskventilationoftheupperairway,difficultywith
trachealintubation,orboth
DifficulttoVentilate-
iswhensignsofinadequateventilationcouldnotbereversedbymaskventilationor
oxygensaturationcouldnotbemaintainedabove90%
DifficulttoIntubate-
iswhenatrainedAnesthetistusingconventionallaryngoscopetake’smorethan3
attempts

4. DISCUSSION
4

5. Degrees of Airway Difficulty
5

6. Overlap
Difficult
Mask
Ventilation
6

7. Overlap
Difficult Mask
Ventilation
7
Difficult
SGA

8. Triple Failure
Difficult
SGA
8
Difficult
Mask
Ventilation
Difficult
Intubation
DANGER ZONE

9. An Emergent Surgical Airway is Not
Always Assured
Difficult
Mask
Ventilation
9
Difficult
Intubation
Difficult
surgical airway
Danger Zone

10. 4
th
National Audit Project NAP4
10
•Sept2008-Sept2009estimated
2,900,000GAperformedintheUK
•Datacollectedon114,904GA’sfrom
309hospitalsovera2weekperiod
•184seriousairwaycomplications,
including:
-Death(14)
-BrainDamage
-EmergentSurgicalAirway
-UnexpectedICUadmission

11. NAP4 Lessons Learned
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12. NAP4 Lessons Learned
PoorAirwayAssessment&PoorPlanningcontributedtoPoor
Outcomes
1.Failuretomatchstrategytoassessment(technique)
2.Failuretohavepreparedstrategy(planBandC)
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13. NAP4 Lessons Learned
13
EmergencyPercutaneous
Cricothyrotomyfailed
60%ofthetime

14. NAP4 Lessons Learned
Acommonthemewas“failuretoplanforfailure”
•Insomecaseswhenairwaymanagementwasunexpectedlydifficult
theresponsewasunstructured.Inthesecasesoutcomeswere
generallypoor.
•Theprojectidentifiednumerouscaseswhereawakefiber-optic
intubationwasindicatedbutnotused
14

15. NAP4 Lessons Learned
•Aspirationwasthesinglemostcommoncauseofdeathinanesthesia
events
•Importantlymostaspirationsoccurduetofailuretorecognizerisk
factorsandfailuretoadjusttheanesthetictechniqueaccordingly
•Aspirationremainsthemostfrequentcauseofairwayrelateddeaths
duringanesthesia.
15

16. NAP4 Lessons Learned
Onethirdoftheeventsoccurredduringemergenceorinrecovery.Obstruction
wasthecommoncauseintheseevents
Recommendations:
•NasalTrumpets
•OralAirway
•Airwayexchangecatheter
•SGApriortoremovalofETT(BaileyManeuver)
•AwakenpatientwithSGAinplace
16

17. Predictors of Difficult Mask Ventilation
•Beard
•OSA
•Obesity
•MaleGender
•MallampaticlassIIIorIV
•NeckCircumference
17

18. Predictors of Difficult
Intubation
•InadequatePreoperativeAssessment.
•Historyofdifficultintubation
•Inadequateequipment
•Experiencenotenough.
•Poortechnique.
•IncreasedAge
•MallampatiIIIorIV

19. Anatomical Factors Affecting Laryngoscopy
•Neck Circumference (Single Major Predictor in Obese)
•Short Neck.
•Protruding incisor teeth.
•Long high arched palate.
•Increase in either anterior depth or Posterior depth of the mandible decrease
in Atlanto Occipital distance
•Limited cervical range of motion
•Small mouth opening
•Temporomandibular joint pathology

20. Basic Airway Evaluation in All
Patients
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•Previousanestheticproblems
•Generalappearanceoftheneck,face,maxillaandmandible
•Jawmovements
•Headextensionandmovements
•Theteethandoropharynx
•Thesofttissuesoftheneck
•Recentchestandcervicalspinex-rays

21. Think L-E-M-O-NWhen Assessing a
Difficult Airway
Lookexternally.
Evaluatethe3-3-2rule.
Mallampati.
Obstruction?
Neckmobility.

22. L:Look Externally
•Obesityorverysmall.
•ShortMuscularneck
•Largebreasts
•ProminentUpperIncisors(BuckTeeth)
•RecedingJaw(Dentures)
•Burns
•FacialTrauma
•Stridor
•Macroglossia(LgTongue)

23. E-Evaluate the 3-3-2 Rule
•3fingersfitinmouth
•3fingersfitfrommentumtohyoidcartilage
•2fingersfitfromthefloorofthemouthtothetopofthe
thyroidcartilage
23

24. E-Evaluate the 3-3-2 Rule
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25. M-Mallampati classification
Class-I
Class-II
Class-III Class-IV
soft palate, fauces;
Uvula, pillars.
the soft palate, fauces
and uvula
soft palate and base of uvulaOnly hard palate

26. Mallampati ?
26

27. 27
Cormack & Lehane Grading

28. O-Obstruction
Blood
Vomit
Teeth
Dentures
Epiglottis
Tumors
Foreign Body (piercings)
28

29. N-Neck mobility -Measurement of
Atlanto-Occipital Angle

30. Atlanto-Occipital Angle
30
Estimatestheangletraversedbythe
occludedsurfaceoftheupperteeth
GradeI--->35°
GradeII–-22-34°
GradeIII–12-21°
GradeIV--<12°

31. Thyromental Distance
31
•Measurefromupperedgeofthyroidcartilagetochinwiththehead
fullyextended.
•Ashortthyromentaldistanceequateswithananteriorlarynx
•Greaterthan7cmisusuallyasignofaneasyintubation
•Lessthan6cmisanindicatorofadifficultairway
•Relativelyunreliabletestunlesscombinedwithothertests

32. Thyromental Distance
32

33. MANAGEMENT PLAN OF ANTICEPATED
DIFFICULT AIRWAY
1.Discussionwithcolleaguesinadvance
2.Equipmenttestedbefore
3.Seniorhelpbackup
4.Definiteinitialplan(A)forventilationandintubation
5.Definiteplan(B)thanoptionofawakeintubation
6.Idealsituationsurgeryteamstandby

34. Preoxygenation
TwoTechniquesCommoninUse:
1. Tidalvolumebreathing(TVB)of100%oxygenviaatight-fittingfacemaskfor5minutes
(PreferredMethod)
2. Deepbreaths/VitalCapacity4timeswithin0.5min(Timetodesaturationisconsistently
shorterthenpreferredmethod)
WhyPreoxygenate?
•O2ConsumptionVo2=250ml/minand2500mlO2inFRC(afterpreO2)=10minutestousethis
O2

35. Airway Management A-B-C
StartwithPlanA
IfplanAfails-
GotoplanB
IfplanBfails-
GotoplanC

36. Plan “A”: (ALTERNATE)
•DifferentLengthofblade
•DifferentTypeofBlade
•DifferentPosition
•DifferentEquipment

37. Plan “B”: (BVM and BLIND INTUBATION
Techniques )
•MaskVentilation
•Bougie
•Combi-Tube?
•LMAanOption?
•Fiberoptic?

38. Plan-C Can’t Intubate.. Can’t Ventilate
•NeedleCricothyrotomy
•TranstrachealJetVentilation
•RetrogradeWireIntubation

39. Failure.. Why does it happen
•Nocriticaldiscussionwithcolleaguesaboutproposedmanagement
plan
•Norequestforexperiencedhelp
•Exaggeratedideaofpersonalability
•Ill-conceivedplanAand/orplanB
•PoorlyexecutedplanAand/orplanB
•PersistingwithplanAtoolong,startingtherescueplantoolate
•Notinvolving,andpreparing,surgicalcolleagues
39

40. 40
GALLERY
OF
TOOLS

41. Rigid Laryngoscope Blades Of Alternate
Design And Size
41
Macintosh
Magill
Miller
Polio
Mc Coy

42. 42
Video Laryngoscopy
Airtraq
McGrath
C-Mac

43. Video Laryngoscopy
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•VLCallsonaAlternativeSkill
Set
•In CriticalSituations
UnpracticedTechniquesmay
notbeHelpful

44. Video Laryngoscopy
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•Useastyletandshapeitto
matchyourVLBlade
•Watchthepatientnotthe
monitorwhen
•insertingtheVLBlade
•Troublepassingtube
-Withdraw
-LiftLess
-Dropyourangle

45. Video Laryngoscopy Versus Direct
Laryngoscopy
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•ImprovedGlotticView
•Experienced vs
Inexperienced
•Cost
•Standardofthefuture?
•PictureConfirmation?

46. Bullard Rigid Fiberoptic
Laryngoscope
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•Time
•Experience
•LimitedManeuverability

47. Stylet Devices
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Lighted Stylet
Optical Stylet
•NoNasalIntubation
•NoSuction
•LimitedtoaboveCords

48. 48
GUMELASTICBOUGIE(GEB)
–FirstusedinEngland
–Cheap
–Goodinpatientsinwhom
onlyepiglottisisvisualized

49. Supraglottic Airways SGA
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Combitube LMA

50. The Esophageal-
Tracheal Combitube
50
•Usefulasemergencyairway
•Twolumensallowfunction
whetherplaceinesophagusor
trachea
•Esophagealballoonminimizes
aspiration

51. Laryngeal Mask Airway

52. VARIATIONS OF LMA
•LMA–Classic(standard)
•LMA–Flexible(reinforced)
•LMA–Unique(disposableLMA)
•LMA–Fastrach(intubatingLMA)
•LMA–C-Trach(Visualization/Intubation)
•LMA–Proseal(gastricLMA)
52

53. LMA –Fastrach (Intubating LMA)
•Rigid,anatomicallycurved,airwaytube
thatiswideenoughtoacceptan8.0mm
cuffedETTandisshortenoughtoensure
passageoftheETTcuffbeyondthevocal
cords
•Rigidhandletofacilitateone-handed
insertion,removal
•Epiglotticelevatingbarinthemask
aperturewhichelevatestheepiglottisas
theETTispassedthrough
•Availableinthreesizes,onesizefor
children,twosizesforadults
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54. LMA C-Trach
•Ventilation
•Visualization
•Intubation
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55. LMA-Proseal
•Highsealpressure-upto30cmH
20
-Providingatightersealagainstthe
glotticopeningwithnoincreasein
mucosalpressure
•Providesmoreairwaysecurity
•EnablesuseofPPVinthosecases
whereitmayberequired
•Abuilt-indraintubedesignedto
channelfluidawayandpermit
gastricaccessforpatientswith
GERD
55

56. LMA-Proseal
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57. Fiberoptic Aided Intubation
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•MostVersatileToolAvailablefor
DifficultIntubation
•OpticalElementsareSmall
•VisualizationBelowthe Cords
•AwakeIntubation
•UniqueSkillset
•LensContamination
•Cost

58. Can’t Ventilate/Cant Intubate
58

59. Cricothyrotomy
59
•Airwayestablishedthrough
theCricothyroidMembrane
•NotaTracheostomy
•LargeBoreCatheter
•Expectedskillofthe
Anesthetist
•ContraindicatedinNeonates
andChildrenunderage6

60. Transtracheal Jet Ventilation
60
•Maxillofacial,Pharyngeal,or
LaryngealTrauma,Pathology
orDeformity
•16-GaugeorLarger(16g-tidal
volume400-700)
•15-30psiwithInsufflation1-
1.5sec.
•Specializedsystemscapableof
usingLow-pressureO2

61. Retrograde Intubation
•LocalAnesthesiaoftheairway,skinwheelatpuncturesite.
•Cricothyrotomyperformedwithairaspiration
•Retrogradewireisadvanceduntilitemergesfromthemouth.
(MagillForceps)
•WireisClamped/Securedattheentrysite
•ETTadvancedoverthewire(ManyTechniques)
•WireremovedleavingETTinplace
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62. Retrograde Intubation
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63. Extubation of the Difficult Airway
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64. Airway Exchange Catheter
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Extubationinacontrolledmanner
withaAEC
•Welltolerated
•Airwaycanbereintubated
•CandeliverOxygen
•Providesanavenueforsuction

65. Airway Exchange Catheter
•LocalizetheairwaythroughexistingETT
•MarkAECatrequireddepth(tubedepth+3CM)
•InsertAECandremoveETT
•TapeAECinplace
•AssessforremovalofAEC
65

66. Bailey Maneuver
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ExchangeofETTforaLMA
DecreasedSeverityof
•Cough
•MaximumchangeSBP
•MaximumchangeHR
•Sorethroat

67. Bailey Maneuver
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•PatientisDeep
•Oral-pharyngealsuction
•DeflatedLMA placed
behindETT
•LMAcuffinflated
•ETTcuffdeflatedand
removed
•LMAusedforventilation

68. 68
2003 2013
What's New in the ASA Difficult Airway
Algorithm

69. 69
What's New in the ASA Difficult Airway Algorithm
Assess Likelihood and Impact section.
Added:
Difficult Supraglottic airway placement
Separated: Intubation and Laryngoscopy

70. 70
2003 2013
What's New in the ASA Difficult Airway Algorithm
Basic Management Choices:
Video-assisted Laryngoscopy as
initial approach to Intubation

71. 71
2003 2013
What's New in the ASA Difficult Airway Algorithm
“LMA” changed to “SGA”

72. 72
2003 2013
What's New in the ASA Difficult Airway Algorithm
Video-Assisted Laryngoscopy: Listed first
under Alternative Difficult Intubation
Approach

73. 73
2003 2013
What's New in the ASA Difficult Airway Algorithm
Under Invasive Airway
Access: Percutaneous airway
techniques and jet ventilation
remain but are
de-emphasized

74. Two For The Road
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75. Two For The Road
Befamiliarwithalternativeintubatingtechniquesand
usethemonaregularbasisinyourdaytoday
practice.
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76. THANK YOU
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